Knowledge, Attitudes and Practice towards COVID-19 Vaccinations: A Cross Sectional Community Survey in Sudan

Introduction

Coronavirus disease (COVID-19) caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has been reported as major public health problem worldwide since March 11, 2020 [1, 2]. The clinical presentation of disease range from asymptomatic to severe acute pneumonia and other multi-organ complications and represents a real threat to population worldwide [3, 4, 5, 6]. By December 2021 more than 281, 808,270 confirmed cases and nearly 5,411,759 COVID-19 deaths had been reported globally [3]. The incidence is higher in the Americas (102,287,397 cases and 2,404,354 deaths) and Europe (99,133,183 cases and 1,661,105 deaths) than in South East Asia (44,933,587

cases and 720,545 deaths), Africa (7,164,485 cases and 155,675 deaths) and the Western Pacific (11,165,866 cases and 154,667 deaths) [3]. The true scale of COVID-19 in most countries is much greater than these reported figures. The first coronavirus case in Sudan was reported on March 12, 2020. Since then, the numbers of new cases have been rising rapidly in the country [7, 8]. As of 02 October 2021, the country has recorded 38,263 positive cases of COVID-19 and 2902 deaths domestically [7, 8].

Protective measures are essential in pandemic management [9] and Vaccines are the most important public health measure and most effective strategy to protect the population from COVID-19 [10, 11, 12]. Several prophylactic vaccines against COVID-19 have already been developed in various countries, including vaccines produced by Astra Zeneca, Pfizer– BioNTech, Moderna, and Johnson & Johnson (Janssen). These vaccines have been distributed to various countries. With the distribution of vaccines underway, it is very important to examine community acceptance of COVID-19 vaccinations [13, 14, 15, 16, 17, 18, 19, 20]. Vaccine hesitancy has been a concern since even before the current pandemic [21]. A recent global review found that 72% of people would take a vaccine against COVID-19 if it were proven safe and effective, but willingness varied widely between the included nations [14]. Differences in acceptance rates among the 19 countries included in this survey ranged from almost 90% (in China) to less than 55% (in Russia) [14]. In general, factors related to vaccine hesitancy, as reported in the literature, include religious reasons, personal beliefs, and safety concerns, including the association of vaccines with myocarditis, pericarditis, and brain damage, and other conditions [22]. Mistrust towards healthcare professionals and health authorities and governments in general were documented in the literature as major influencers in intentions to get vaccinated [23, 24]. Additionally, vaccine hesitancy level differs across the different vaccines; the factors related to acceptance of the influenza vaccine, for example, may not apply to the new COVID-19 vaccines [25]. Therefore, investigating the factors related to the COVID-19 vaccine in specific contexts and cultures is necessary to identify factors influencing the decision to become vaccinated or not.

In Sudan, the government has already started the formal COVID-19 vaccination programme in the second week of March 2021 targeting healthcare workers primarily, then the elderly (over 50 years old) and patients with chronic disease. Although there are numerous vaccination services in Sudan, the complete newness of the COVID-19 vaccination roll-out poses questions about the distribution and acceptance of vaccines in this country. It also poses questions about the general population’s knowledge, attitudes and perceptions towards the COVID-19 vaccine and vaccination rollout. The presents study conducted to assess the knowledge, attitudes and perceptions towards COVID- 19 vaccinations in Sudanese population Sudan.

Results

A total of 3310 responses were collected and subsequently used in the analysis. As shown in Table 1, the majority of the participants were female (64.35%). More than half (55.92%) of the participants were Adult (>25years). The majority of participants (65.68%) were single and had university/ higher levels of education (56.22%) (Table 1). About 53.72% of the participants were residence in Khartoum state. The distribution of each knowledge item about the COVID-19 vaccine is presented in Table 2. The majority of the respondents are knowledgeable about the approved COVID-19 vaccines (55.55%). The study also revealed that majority of respondents were believed that COVID-19 vaccination could not protect them from infection with COVID-19 (58.70%), and after getting a COVID-19 vaccine, they can still test positive for COVID-19 on a viral test (75.64%). They think the COVID-19 vaccine is necessary only for travelling purpose (70.24%). Unfortunately the majority of respondents do not followed the recommended guideline for COVID-19 adequately (84.89%).Meanwhile, a smaller percentage of respondents they need to encourage their family and friends to receive a COVID-19 vaccine (21.75%).

Findings shown in Table 3 indicate that majority of the participants have a positive behavior toward the COVID-19 national prevention guideline. The majority of participants does not touch their eyes, nose and mouth with unwashed hands (80.54%); Avoid close contact with people who are sick (76.44%); Use an alcohol-based hand sanitizer (70.15%); cover their mouth and nose with a tissue or use their elbows when coughing/sneezing (59.90%); avoid eating or gathering at restaurants, and food courts(53.17%). Findings presented in Table 4 indicate that the attitudes of the majority of the respondents’ toward COVID-19 vaccine include worries about the unforeseen effect (88.27%), preference for natural immunity (66.55%).This belief was even more emphasized when (51.75%) were did not believe in the benefits of COVID-19 vaccines outweigh their reported side effects (Table 5). In general, 52.56% they think have enough information about theCOVID-19 vaccines and their safety, and 57.89% were not inclined to consent when a new vaccine is introduced, in general. 57.88% of our participants did not hear about anyone who does not want to take the vaccine because of cultural or religious values (Table 5).

Discussion

Vaccination is an important measure to control COVID-19 global pandemic, Efforts were began in many African countries in early 2021 to build public trust in COVID-19 vaccination campaigns [6, 9]. The most hopeful way of controlling COVID-19 could be universal vaccination to achieve herd immunity [26]. In Sudan, the government has already started the formal COVID-19 vaccination programme in the second week of March 2021 targeting healthcare workers primarily, then the elderly (over 45 years old) and patients with chronic disease. Sudan is a participant in the COVAX facility and requested 17million doses of Covid-19 vaccine to cover 8.5 million people, representing 20% of its population. With the distribution of vaccines underway, it is very important to examine community acceptance of COVID-19 vaccinations [13, 14, 15, 16, 17, 18, 19, 20]. Vaccine hesitancy has been a concern since even before the current pandemic [21]. Our results showed that respondents’ are knowledgeable about COVID-19 vaccines that have already been approved for use, but their knowledge on vaccines that are not meant for COVID-19 is inconsistent (Table 2). The findings also revealed that participants have a positive behavior toward COVID-19 national prevention guidelines, and that they complied with these guidelines (Table 3). The study revealed that 57.89% of respondents they did not feel they were at risk but only 22.23% believing that they were at personal risk of being infected (Table 2). Majority of the participants believed a COVID-19 vaccine was not needed because the immune system (Table 4) is more effective at tackling the virus, that the mortality rate of COVID-19 does not warrant a vaccine and that the pandemic has not been particularly severe in Africa [3].

Largesurvey by an Africa CDC from 13 out 15 counties, with total number of 13,699participants from Burkina Faso (n=1037); Côte D’Ivoire (n=1039); DRC (n=1007); Ethiopia

(n=1001); Gabon (n=1112); Kenya (n=1000); Mali (n=1009); Nigeria (n=1172); Niger (n=1173); Senegal (n=1010); South Africa (n=1056); Sudan (n=1075); Uganda (n=1008) found the highest overall acceptance toward COVID-19 vaccination : 79% of respondents would agree to take a COVID-19 vaccine if it was deemed safe and effective. Ethiopia (94%) reporting the highest acceptance rate and the DRC (59%) the lowest [27]. In contrast, the present study reports low acceptance of COVID-19 vaccination among the respondents (84.35%) (Table 1). The low acceptance of COVID-19 vaccination was also reported from China which revealed only about 28.7% reported a definite intention [15]. In contrast a study showed a higher COVID-19 vaccine intention in Malaysia (94.3%) [28], France (74%) [29], United States (74.1%) [30] and Europe (73%) [31] Indonesia (67%) [32] and Japan (67.1%) [33]. Also, an online survey also found a higher vaccine intention in. According to a global survey of 19 nations, 71.5% of the participants said they would get the COVID-19 vaccine if available [33].

Vaccine acceptance may need to be improved further, as high vaccination coverage is needed to combat epidemics [33]. Attitudes towards vaccination were affected by popular understandings of the virus: its origins, perceived risk profile such as mortality and severe illness rates, ideas of natural immunity and the impact of variants on vaccine effectiveness. One of the principal factors behind these attitudes seems to be a concern that the new vaccines will not be safe and Vaccine developed during an epidemic/pandemic could not be considered guaranteed (Table 1) and (Table 6). Trust in the authorities, including medical institutions was seen in several studies as an indicator for vaccine acceptance and confidence in vaccine safety. Healthcare professionals and medical institutions including the WHO were seen to have an important role to play in vaccination communication and engagement [34].

Conclusion

Before and during vaccine rollout, practical ways to eliminate vaccination barriers in Sudanese populations must be implemented, including effective communication and supervision. Cultural considerations, differing understanding and attitudes about disease causes, and essential information and concerns about vaccine safety and efficacy alleviating these concerns and enhancing public confidence in COVID-19 vaccines are crucial for future vaccination strategies and immunization programs against the COVID-19 pandemic.

Acknowledgements: The authors would like to express the most profound gratitude to all of the respondents who participated in this study.

Authors’ contributions: NAM was provided conceptual framework for the project, participated in data collection, analysis and writing the manuscript.